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Dosing Exam 1 > Oral Anticoagulants > Flashcards

Oral Anticoagulants Flashcards

1
Q

Coumadin (warfarin) MOA

A

Inhibitors VKOR complex to reduce Vit K available for SNOT, protein C and protein S

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2
Q

S-warfarin has problem with

A

2C9

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3
Q

R warfarin has problems with:

A

1A2 > 3A4 > 2C19

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4
Q

Warfarin dosing

A

Initiated 5 mg daily with possible LD of 10 mg x 2 days before maintenance regimen

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5
Q

Use 2.5 mg of warfarin if:

A 
Greater than 75 y.o.
Liver or renal disease
HF
High bleed risk
Concurrent therapy
Acute EtOH intake
Smoking cessation
Poor nutritional status
Infection
Malignancy
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6
Q

Testing for 2C9 and VKORC1 =

A

Not recommended!!

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7
Q

Increased warfarin efficacy or bleeding:

A 
Amiodarone
Fluconazole
Metronidazole
NSAIDs
Bactrim
Herbals with "G"
Other anticoagulants
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8
Q

Decreasing warfarin efficacy:

A

Rifampin
St. John’s Wort
Carbamazepine

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9
Q

Normal INR

A

~1

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10
Q

Afib

VTE treatment/prevention

A

2-3

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11
Q

Triple therapy (ASA + P2Y12 inhibitor + warfarin) INR

A

2-2.5 + GI prophylaxis

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12
Q

Less than 1.5

A

Increase total weekly dose 10-20%

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13
Q

1.5-1.9

A

Increased total weekly dose 5-15%

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14
Q

2-3

A

Continue

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15
Q

3.1-3.5

A

Decrease total weekly dose 5-15%

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16
Q

3.6-4.4

A

Decrease total weekly dose 10-20% and hold for 1-2 doses

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17
Q

Yes signs/symptoms of major bleed, treat with:

A

Vit K 10 mg IV + FFP 15-30 mL/kg OR PCC (preferred)

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18
Q

No signs/symptoms of major bleed + 4.5-10, treat with

A

Hold 1-2 doses
Recheck INR in 2-3 days
Minor bleed or risk of bleeding: Vit K 1-2.5 mg PO

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19
Q

No signs/symptoms of major bleed greater than or equal to 10, treat with

A

Vit K 2.5-5mg PO

Hold Coumadin

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20
Q

Fresh Frozen Plasma (FFP)

A

Immediate reversal, may lead to volume overload

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21
Q

Vit K1

A

12-24 hr peak effect, large doses may result in resistance

22
Q

Prothrombin Complex Concentration (PCC)

A

Immediate reversal
Expensive
Wears off after ~6-8 hours

23
Q

Initiation outpatient followup

A

Recheck in 5-7 days

24
Q

Out of range less than 4.5 or 1 INR in range followup

A

1-2 weeks

25
Q

Greater than or equal to 2 INRs within range

A

4 -12 weeks

26
Q

Severe bleeding (hospitalized) INR followup

A

PRN until bleeding stops

27
Q

INR greater than 10 followup

A

1-2 days

28
Q

INR 4.5-10 followup

A

2-3 days

29
Q

Warfarin in the hospital

A 
Obtain baseline INR 
Evaluate current interactions
Counsel on importance of monitoring, compliance, drug-food interactions, ADRs
Monitor INR on regular basis
Titrate
30
Q

Bridging therapy is used:

A

VTE
Severe thrombophilia
Afib
Valve replacement

31
Q

Bridge therapy =

A

warfarin and parenteral on day 1 of hospitalization

32
Q

Continue IV heparin or SQ low-molecular weight heparin until:

A

Warfarin use for at least 5 days

Two INRs above 2.0, 24 hours apart

33
Q

Pradaxa (dabigatran) DVT/PE Dosing

A

150 mg PO BID with 5-10 days of IV anticoag first

Less than or equal to 30 CrCl = do not use

34
Q

Pradaxa (dabigatran) Non-valvular Afib Dosing

A

150 mg PO BID

CrCl 15-30: 75 mg PO BID

35
Q

Pradaxa (dabigatran) MOA

A

Direct thrombin inhibitor

36
Q

Xarelto (rivaroxaban) MOA

A

Factor Xa inhibitor

37
Q

Xarelto (rivaroxaban) Acute DVT/PE Dosing

A

15 mg PO BID x 21 days then 20 mg PO daily

Don’t use if CrCl is less than 30

38
Q

Xarelto (rivaroxaban) Nonvalvular afib dosing

A

20 mg PO daily
CrCl 15-50 : 15 mg PO daily
Less than 15 do not use

39
Q

Xarelto (rivaroxaban) Hip/knee DVT thromboprophylaxis dosing

A

10 mg PO daily up to 35 days

Don’t use if CrCl is less than 30

40
Q

Eliquis (apixaban) MOA

A

Factor Xa inhibitor

41
Q

Eliquis (apixaban) Acute DVT/PE Dosing

A

10 mg PO BID x 7 days then 5 mg PO BID

SCr greater than 2.5 or CrCl less than 25 don’t use

42
Q

Eliquis (apixaban) Nonvalvular Afib dosing

A

5 mg PO BID

Do not use if CrCl is less than 25

43
Q

Eliquis (apixaban) Nonvalvular Afib dosing Adjust

A

Adjust to 2.5 mg PO BID if two of the following (Scr greater than 1.5, greater than 80 yo, less than 60 kg)

44
Q

Eliquis (apixaban) Hip/Knee DVT thromboprophylaxis dosing

A

2.5 mg PO BID

Do not use if CrCl less than 30

45
Q

Savaysa (edoxaban) MOA

A

Factor Xa inhibitor

46
Q

Savaysa (edoxaban) Acute DVT/PE Dosing

A

60 mg PO daily with 5-10 days of IV anticoag

If less than 60 kg use 30 mg PO daily

47
Q

Savaysa (edoxaban)Acute DVT/PE Dosing Adjust

A

15-50 CrCl use 30 mg PO daily

Don’t use if less than 15

48
Q

Savaysa (edoxaban) Nonvalvular Afib Dosing

A

60 mg PO daily

49
Q

Savaysa (edoxaban) Nonvalvular Afib Dosing Adjust

A

Greater than 95 do not use
15-50 use 30 mg PO daily
Less than 15 do not use

50
Q

Pros to Oral Anticoagulants

A

Lower bleeding risk than warfarin
No regular lab monitoring
Consistent dosing
Less interactions

51
Q

Cons to Oral Anticoagulants

A

No reversal agent
Pradaxa- dialysis
Others - activated prothrombin complex concentration
Not good for renal impairment or dialysis pts
Specific dosing can be confusing

Dosing Exam 1 (8 decks)

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